Medical Preexisting Condition

[Alphim]

Good morning,

How do the medical insurance people determine what is a preexisting condition?

 

Five months so my wife had some trouble with wrist, no operation just an injection. We did not have insurance at the time.

Recently a  bone spur stated developing on the same wrist, an operation was called for.

On contacting the Insurance I was told it is a preexisting condition. Arguing didn't get me anywhere

except to the hospital cashier to pay Thb70,000.

My question ---- 5 years ago I had Spinal  Stenosis operation If I had to go for an operation on my spine now would 

the insurance company pay for the procedure, or declare it a Preexisting condition ? 

 

Any feedback would be appreciated. Thank you

[scubascuba3]

11 minutes ago, Alphim said:

My question ---- 5 years ago I had Spinal  Stenosis operation If I had to go for an operation on my spine now would 

the insurance company pay for the procedure, or declare it a Preexisting condition ? 

They might even cancel your policy if they find it's an undeclared pre-existing condition, even ask for a refund of any claims paid to date on anything even unrelated

[Etaoin Shrdlu]

It would depend upon several things. Did you declare spinal stenosis as an existing medical condition when you took out the policy? If so, did the insurer exclude all treatments of the spine, or only spinal stenosis or related conditions? 

 

Is your policy issued by a Thai insurance company or one from overseas? Depending upon the jurisdiction, there may be limits on an insurer's ability to cite non-disclosure as a means for denying a claim. Under the Thai Civil and Commercial Code, an insurer can void a policy or deny a claim for material non-disclosure. There is a five year time bar for insurers to cite non-disclosure, but I'm not sure whether the time bar is absolute or pertains only to unintentional non-disclosure. Insurers in other countries may be subject to differing time bars or none at all. The time bar would apply from the date of inception of the first policy issued by the insurer, not the date of treatment.

Edited July 9, 2023 by Etaoin Shrdlu

[Alphim]

1 minute ago, scubascuba3 said:

They might even cancel your policy if they find it's an undeclared pre-existing condition, even ask for a refund of any claims paid to date on anything even unrelated

They would call it a preexisting after 5 yeas? The operation was a success and no problems since. 

[Etaoin Shrdlu]

1 minute ago, Alphim said:

They would call it a preexisting after 5 yeas? The operation was a success and no problems since. 

Yes, the condition for which treatment was sought pre-dated the inception of the policy. An insurer would expect this type of condition to be declared.

[Alphim]

4 minutes ago, Etaoin Shrdlu said:

It would depend upon several things. Did you declare spinal stenosis as an existing medical condition when you took out the policy? If so, did the insurer exclude all treatments of the spine, or only spinal stenosis or related conditions? 

 

Is your policy issued by a Thai insurance company or one from overseas? Depending upon the jurisdiction, there may be limits on an insurer's ability to cite non-disclosure as a means for denying a claim. Under the Thai Civil and Commercial Code, an insurer can void a policy or deny a claim for material non-disclosure. There is a five year time bar for insurers to cite non-disclosure, but I'm not sure whether the time bar is absolute or pertains only to unintentional non-disclosure. Insurers in other countries may be subject to differing time bars or none at all.

Thanks you

It was really a hypothetical question, brought on by my wifes experience,  but I am having some trouble with my. I would think it should be assessed of where on the spine the op was for, but I've found in my short time in Thailand the rules are quite different.

 

 

 

[Alphim]

6 minutes ago, Etaoin Shrdlu said:

Yes, the condition for which treatment was sought pre-dated the inception of the policy. An insurer would expect this type of condition to be declared.

In that case how far must one go back in one's medical history, is there a time limit?

[Ralf001]

5 minutes ago, Alphim said:

In that case how far must one go back in one's medical history, is there a time limit?

Only as far back as to when Jesus was a baby filling nappies.

[Etaoin Shrdlu]

Just now, Alphim said:

In that case how far must one go back in one's medical history, is there a time limit?

No, there is no time limit under the Thai Civil and Commercial Code on how far an insurer can go back through your medical records trolling for undeclared medical conditions. The only time bar mentioned in the Code relates to the number of years that the insurer has been covering the policyholder under their policy or policies.

 

After being continuously insured by the same insurer without interruption for at least five years, there is some protection in terms of a time bar preventing the insurer from citing non-disclosure as a reason to deny a claim or void a policy. I am not sure how absolute that time bar would be, so intentional non-disclosure, which may be insurance fraud, may not withstand the time bar.

[connda]

42 minutes ago, Alphim said:

My question ---- 5 years ago I had Spinal  Stenosis operation If I had to go for an operation on my spine now would 

the insurance company pay for the procedure, or declare it a Preexisting condition ? 

Insurance underwriter spend a huge amount of their operating expense to reject claims based on any reason.
Don't admit it?  They cancel your insurance and refuse to pay. 

It's a hell of a legal scam. 

[scubascuba3]

40 minutes ago, Alphim said:

They would call it a preexisting after 5 yeas? The operation was a success and no problems since. 

when i completed an application form, one question was, have you ever suffered from blah blah blah.

 

I think with a western health insurance company questions are worded asking about the last 2 or 5 years, but check what you completed for your questionnaire, because if there's a subsequent court case that will be evidence

Edited July 9, 2023 by scubascuba3

[Etaoin Shrdlu]

3 minutes ago, scubascuba3 said:

when i completed an application form, one question was, have you ever suffered from blah blah blah.

 

I think with a western health insurance company questions are worded asking about the last 2 or 5 years, but check what you completed for your questionnaire 

I've seen such wording on application forms as well, including here in Thailand, but referring to medical procedures or operations undertaken within the previous ten years. This wording was probably carried over without question from the insurer's home country (it was the local operation of a foreign insurer) where there may be an absolute time bar of ten years. 

 

This is a potential trap for applicants because it contradicts the Thai Civil and Commercial Code's requirement for disclosure without time limitation. The form did not state that medical treatments prior to ten years were exempt, nor did it say that the insurer would waive the ability to cite intentional non-disclosure. I know of a case where this situation arose and I urge great caution if confronted with an application that contains this or similar wording.

[scubascuba3]

5 minutes ago, Etaoin Shrdlu said:

 

 

This is a potential trap for applicants because it contradicts the Thai Civil and Commercial Code's requirement for disclosure without time limitation. The form did not state that medical treatments prior to ten years were exempt, nor did it say that the insurer would waive the ability to cite intentional non-disclosure. I know of a case where this situation arose and I urge great caution if confronted with an application that contains this or similar wording.

Maybe better to disclose it if outside of the date range mentioned, in theory it shouldn't effect the premium and cover....maybe

Edited July 9, 2023 by scubascuba3

[Etaoin Shrdlu]

Just now, scubascuba3 said:

Maybe better to disclose it if outside of the date range mentioned, in theory it shouldn't effect the premium....maybe

The undisclosed operation was a major one and would certainly have affected the insurer's pricing of the policy and may well have resulted in the application being denied. The policyholder claimed he had no subsequent treatment or took any prescription medication. If this was the case, he was neglecting a major health issue.

 

He cited the request on the form to list any operations within the previous ten years as negating his duty to disclose any operation prior to that. There was also wording elsewhere on the application that asked that any medical condition be disclosed, but the policyholder thought he was "cured", which was at the very least extremely debatable.

 

The insurer admitted the application form was flawed, but cited the Thai Civil and Commercial code which requires declaration of material facts without limitation. . In the end, there was a compromise, but before that there was quite a "discussion" with the insurer. The insurer went so far as to seek legal advice on the matter. 

 

If in doubt, disclose, or at least question the insurer on this point and get any response in writing.

[simon43]

4 hours ago, Alphim said:

In that case how far must one go back in one's medical history, is there a time limit?

When I recently applied for medical insurance, (after my existing provider cancelled my policy for failing to declare a pre-existing condition from some 8 years ago), I declared EVERY medical condition and treatment that I have had from 11 years old........ ????

[simon43]

1 minute ago, simon43 said:

When I recently applied for medical insurance, (after my existing provider cancelled my policy for failing to declare a pre-existing condition from some 8 years ago), I declared EVERY medical condition and treatment that I have had from 11 years old........ ????

Luckily, apart from excluding the 8-year condition, my cover was accepted at normal rates.

[Sheryl]

Your spinal stenosis would definitely be considered a pre-existing condition and likely lead to exclusion of all spinal problems. 

 

Spinal Stenosis is a chronic condition. It dos not go away (though some treatments may reduce or eliminate associated pain) and tends to worsen with age.

 

It helps to understand the insurer's concern. Premiums are calculated assuming the insured is at no more than average risk for any type of claim.  Any underlying or past condition that puts you at more than average risk of a particular problem  undermines that calculation.

 

People often mistakenly assume that because a problem was cured, or is not now requiring treatment, it does not matter for insurance purposes. Sometimes this is true (e.g. a broken bone years ago due to an accident that has fully healed) but in many cases if does alter the odds of future problems.  For example, having had a kidney stone once that was removed or passed, still significantly increases the risk of future stones. 

 

If an insurer deems that a prior or pre-existing problem affects your risk of a claim in future they may:

- still insure you but with a specific  exclusion

- offer to insure you at a higher than average premium

- give you a choice of either the above two things

- decline to insure you. This tends to occur when the pre-existing problem is one that increases risk for multiple diseases/potentially affects multiple body organs. 

 

Insurers do differ in how they treat/view the same medical history. Thai insurers tend to be the most restrictive/least nuanced, in part because their reviews seem to be done by non-medically trained people. The better international insurers have medical panels who review applications, often asking for additional  detailed records of pre-existing or prior illnesses before making a decision.

 

 

 

 

[jerrymahoney]

14 hours ago, Alphim said:

Five months so my wife had some trouble with wrist, no operation just an injection. We did not have insurance at the time.

Recently a  bone spur stated developing on the same wrist, an operation was called for.

On contacting the Insurance I was told it is a preexisting condition.

Recently?

 

What is a bone spur?
A bone spur, also called an osteophyte, is a smooth, bony lump that grows off a bone. Bone spurs develop over long periods of time, usually near joints (where two or more bones meet).

 

https://my.clevelandclinic.org/health/diseases/10395-bone-spurs-osteophytes

[Sheryl]

4 hours ago, jerrymahoney said:

Recently?

 

What is a bone spur?
A bone spur, also called an osteophyte, is a smooth, bony lump that grows off a bone. Bone spurs develop over long periods of time, usually near joints (where two or more bones meet).

 

https://my.clevelandclinic.org/health/diseases/10395-bone-spurs-osteophytes

More to the point, she was already symptomatic, and received treatment, prior to taking out the insurance.

[Alphim]

20 hours ago, Ralf001 said:

Only as far back as to when Jesus was a baby filling nappies.

Nice, you think that up yourself?

[Alphim]

2 hours ago, Sheryl said:

More to the point, she was already symptomatic, and received treatment, prior to taking out the insurance.

Thank you. 

[Ralf001]

2 minutes ago, Alphim said:

Nice, you think that up yourself?

Nice, thanks for taking the time to reply.

[DFPhuket]

When I was applying for insurance in Thailand 4 years ago, I answered each of the applications honestly and indicated I was taking cholesterol and hypertension medications (which kept both well within the normal limits). Some policies would have excluded anything related to the heart as a pre-existing condition, while others didn't. Obviously I went with a policy with no exclusions. 

 

Had I not been going for routine health screenings and managing both conditions I would have been a much worse risk for the insurance company. I felt like I should have been rewarded rather than punished for monitoring and effectively managing my health. 

[Alphim]

14 hours ago, Sheryl said:

Your spinal stenosis would definitely be considered a pre-existing condition and likely lead to exclusion of all spinal problems. 

 

Spinal Stenosis is a chronic condition. It dos not go away (though some treatments may reduce or eliminate associated pain) and tends to worsen with age.

 

It helps to understand the insurer's concern. Premiums are calculated assuming the insured is at no more than average risk for any type of claim.  Any underlying or past condition that puts you at more than average risk of a particular problem  undermines that calculation.

 

People often mistakenly assume that because a problem was cured, or is not now requiring treatment, it does not matter for insurance purposes. Sometimes this is true (e.g. a broken bone years ago due to an accident that has fully healed) but in many cases if does alter the odds of future problems.  For example, having had a kidney stone once that was removed or passed, still significantly increases the risk of future stones. 

 

If an insurer deems that a prior or pre-existing problem affects your risk of a claim in future they may:

- still insure you but with a specific  exclusion

- offer to insure you at a higher than average premium

- give you a choice of either the above two things

- decline to insure you. This tends to occur when the pre-existing problem is one that increases risk for multiple diseases/potentially affects multiple body organs. 

 

Insurers do differ in how they treat/view the same medical history. Thai insurers tend to be the most restrictive/least nuanced, in part because their reviews seem to be done by non-medically trained people. The better international insurers have medical panels who review applications, often asking for additional  detailed records of pre-existing or prior illnesses before making a decision.

 

 

 

 

Thanks Sheryl, yes you are correct, most people probably do think once it's ''cured'' then the problem is finished. I know I did.

[The Fugitive]

57 minutes ago, DFPhuket said:

When I was applying for insurance in Thailand 4 years ago, I answered each of the applications honestly and indicated I was taking cholesterol and hypertension medications (which kept both well within the normal limits). Some policies would have excluded anything related to the heart as a pre-existing condition, while others didn't. Obviously I went with a policy with no exclusions. 

 

Had I not been going for routine health screenings and managing both conditions I would have been a much worse risk for the insurance company. I felt like I should have been rewarded rather than punished for monitoring and effectively managing my health. 

Absolutely agree! A self-employed contracting plumber/gas central heating installer friend has to have health/public liability insurance. That involves annual medicals. At his most recent his doctor asked him if he would like him to install a stent. No problem at the moment but thinking long-term that 'prevention is better than cure'. He agreed. His next insurance premium tripled. They told him; 'because you've had a heart attack'. He replied he hadn't. Well then, 'because you're at risk of having one'. He replied I'm not. Well, 'they certainly don't fit them for fun'. He has to pay 3X more!

[orchidfan]

slightly off topic but where did you get the spinal stenosis surgery done  and what was the cost and long.k term  outcome.?

Where I get medical Treatment in Hong Kong (although LIVING in TH 20+ years......married ) they refuse to do this kind of spinal surgery (too dangerous ) and so only take Pregabalin 

At 73, expat health insurance is far too expensive. .

 

[Scouse123]

On 7/9/2023 at 2:54 PM, Alphim said:

They would call it a preexisting after 5 yeas? The operation was a success and no problems since. 

I had cancer in a certain part of my body and I had an operation 18 years ago, the operation was a success with no recurrence, however, they marked it as a pre condition and anything down in the throat or esophagus relating to cancer is not covered.

[1FinickyOne]

On 7/9/2023 at 3:31 PM, scubascuba3 said:

one question was, have you ever suffered from blah blah blah.

ha ha... don't let them see your forum posts... 

[Sheryl]

On 7/11/2023 at 1:48 AM, Scouse123 said:

I had cancer in a certain part of my body and I had an operation 18 years ago, the operation was a success with no recurrence, however, they marked it as a pre condition and anything down in the throat or esophagus relating to cancer is not covered.

This is because you are at above average risk for it in the future.